Motor Fuel Sales Tax Form

VILLAGE OF MORTON GROVE
MOTOR FUEL SALES TAX

Monthly Remittance Form BKN.MFT.2015
Revised 01/20/2015

Finance Department
Village of Morton Grove
6101 Capulina Avenue
Morton Grove, IL 60053

1. Month/Year of Collection: ____________________

Business Information

2. Business Name: ___________________________________

3. Business Address: __________________________________

4. City, State, Zip Code: ________________________________

5. Telephone: _______________________________________

6. Contact Person: _____________________________________

7. Certificate of Compliance Number: _______________________

8. Illinois Business Tax Number for
Morton Grove Business Location
(from Illinois ST-1): __________________________________

9. Under penalties of perjury and other penalties provided by law, I declare that I have examined this return and to the best of my knowledge and belief it is true, correct and complete. I further declare that the information set forth is taken from the books and records of the business for which this return is filed.

10. Signature of Taxpayer

11. Date: _______________________

12. Signature of Preparer

13. Date: _______________________

14. Preparer's Name, Address, Telephone Number:

15. COMPUTATION OF MOTOR FUEL SALES TAX LIABILITY

16. Gallons of motor fuel sold (ST-1 Schedule
A-deductions. Total of Lines 17,18,19,20,21):

____________________

17. Morton Grove Motor Fuel Tax: Line 16 x 4% (.04):

$ ____________________

18. Late Penalties (penalties will apply after the due date of the return and the payments)

19. Late filing penalty LINE 17 x 10% (.10):

$ ____________________

20. Late payment penalty LINE 17 x 5% (.05):

$ ____________________

21. Interest: LINE 17 x 1.5% x number of months
past due (not to exceed 5% per annum):

Number of Months: _________ Interest Penalty: $ _______________

22. Total Penalty:
Add LINES 19,20,21:

$ ____________________

23. Total amount due and enclosed:
Add LINES 17 and 22

$ ____________________

24. Mail this completed return and a check or money order for the amount shown on line 23. You must include a copy of the Illinois Department of Revenue for ST-1 and Schedule A-Deductions for the period indicated on Line 1.

Send to:
Finance Department
Village of Morton Grove
6101 Capulina Avenue
Morton Grove, IL 60053

VILLAGE OF MORTON GROVE MOTOR FUEL SALES TAX

Business Information

15. COMPUTATION OF MOTOR FUEL SALES TAX LIABILITY

VILLAGE OF MORTON GROVE
MOTOR FUEL SALES TAX